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How do I win my disability case if I can't afford medical care?

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Q:

How do I win my disability case if I can't afford medical care?

A:

Claimants are considered disabled and qualify for Social Security Disability Insurance (SSDI) only if they provide medical evidence to Social Security, which proves theyhave a medically determinable mental or physical impairment that is expected to last 12 continuous months and does not allow them to engage in substantial gainful activity (SGA).

What does the SSA need to determine if a condition is a medically determinable impairment?

To make a disability determination, the Social Security Administration (SSA) will review a claimant’s recent medical records. Specifically, they will review medical evidence—provided by the claimant’s treating sources—that the claimant’s listed impairments are the "result of an anatomical, physiological, or psychological abnormality, which can be shown by medically acceptable clinical and laboratory diagnostic techniques."

Although statements from the claimant regarding their symptoms and impairments will be evaluated by the SSA, the SSA will also need medical evidence documenting their signs and symptoms.

Prior to applying for SSDI benefits, claimants should make sure that they have a diagnosis and prognosis, medical history information, clinical findings, laboratory findings and a medical statement from their treating sources identifying work activities (i.e. sitting, standing, walking, lifting, carrying) that they cannot perform given their impairment(s).

SSA Requests a Consultative Examination

The SSA will make their determination about a claimant’s disability based almost entirely on the medical evidence that they collect from the claimant’s treating sources. If a claimant has not seen a doctor or they have seen a doctor but there is insufficient evidence to make a disability determination, the SSA may schedule a consultative examination (medical examination) for the claimant.

The consultative examination can be conducted by the claimant’s own doctor or by an independent source. The information from the consultative examination, as well as any additional medical evidence, is reviewed by a two-person adjudicative team and then a disability determination is made.

Many claimants assume that if they cannot afford to see a doctor, they can simply get a free medical evaluation through the consultative examination and easily win benefits. Unfortunately, many claimants find that the consultative examination is nothing more than a cursory exam, often lasting less than 10 minutes, and generally does not provide enough evidence about their disability to win SSDI benefits.

No doctor… now what?

So what do you do if you cannot see a doctor and you have no medical evidence proving that you are disabled? Unfortunately, given the state of the current healthcare system and the sky-rocketing cost of medical care, even individuals with medical insurance may have difficulty finding a great doctor. If you do not have medical insurance, the situation can be even more precarious.

While there may be several steps you can take to begin to accumulate medical evidence that you are disabled, there are no good solutions. Several options, however, are discussed below.

Determine if you qualify for Medicaid. Medicaid and the Children’s Health Insurance Program (CHIP) are offered to certain qualifying families, children, pregnant women, the elderly and the disabled. Other low-income families may also qualify under recent state expansion programs. Review Medicaid qualifications at Healthcare.gov.

Visit minor emergency centers. Across the United States, urgent care and minor emergency clinics have opened, offering health care services at a relatively low cost and with no appointment necessary. Although a minor emergency center does not offer treatment for life-threatening emergencies, they can provide medical care for common health conditions. Claimants who cannot afford to consistently see a doctor can visit minor emergency centers and accumulate diagnostic testing and laboratory results for their condition, including blood tests, X-rays, EKGs and ultrasounds. Minor emergency doctors can also provide medical consultations and information about a claimant’s limitations to perform work activities.

Find a doctor who accepts cash payments. A growing number of doctors have decided to avoid the hassle of insurance and have moved to a cash payment-only system. Doctors who accept cash-only may offer medical care at a substantially lower price. Some clinics also offer plans for patients to pre-pay for certain medical services.

Find low-cost medical services. Individuals who do not qualify for CHIP or Medicaid may be able to find low-cost medical care within their community. For example, in the State of Texas, the Texas Department of Health Services contracts with 39 Community Mental Health Centers and NorthSTAR to deliver mental health services in communities across Texas. Online searches may offer more information about options in your community.

Rely solely on the consultative examination. A claimant’s last resort is to rely solely on the medical evidence gathered by the consultative examiner at the consultative examination. As mentioned above, the consultative examination may not provide sufficient evidence to prove that a claimant is disabled. If possible, it is better to establish an ongoing relationship with a qualified doctor who can provide longitudinal data about your health condition and how it has impaired your ability to perform work.